healthsystemtransformation inmyanmar re the … · 2016" !expansion of payroll tax financed...

HEALTH SYSTEM TRANSFORMATION IN MYANMAR: ARE THE CURRENT CHANGES PROMISING?

5/26/2015

Phyu Phyu Thin Zaw, MBBS, PhD VisiHng Scholar/WHO-‐HRP Career Development Fellow

Asia Health Policy Program Shorenstein-‐APARC

1

●  Myanmar profile ●  Myanmar’s current health status ●  Myanmar Health System

●  Overview ●  Comparison with South East Asian countries

●  Equity of access to ReproducBve Health services ●  Current Changes in Myanmar Health System ●  Conclusions and RecommendaBons

2

PoliHcs ❖  Was the second most isolated country next to North Korea from 1962 to 2012 ❖ In a transiBonal period aMer 63 years of military regime ❖ Increased transparency ❖  More freedom of speech, moderate media freedom ❖ Some posiBve approaches

AdministraHve Division • 7 Regions • 7 States Area :Slightly smaller than the U.S. state of Texas. Neighbors : China, India, Thailand, Bangladesh and Laos

❖ Once South East Asia’s wealthiest naBon

(Ref: 2014 census, WHO 2011)

3

Ethnicity • Over 130 ethnic groups with 8 major groups • Internal Conflicts: One of the longest civil wars • Abundant natural resources: 2nd lowest Human Development Index in Asia Pacific Region

Beautiful Myanmar"

http://www.placestoseeinyourlifetime.com/bagan-a-strikingly-beautiful-ancient-city-in-myanmar-8843/ PHOTO CREDIT

Beautiful Myanmar!

World Bank, 2013 Wikipedia contributor 2013

1.  Life Expectancy 2.  Maternal Mortality 3.  Infant Mortality 4.  Prevalence of Communicable Diseases (HIV/

TB/Malaria) 5.  Prevalence of Non-‐communicable diseases

7

Life expectancy in Myanmar Male: 63.4 Female: 67.1 Total: 65.2

8

Maternal Mortality RaHos and Percentage of Skilled Birth AZendant in SEAR

9

"   200 per 100,000 live births "   Three quarters of all maternal

deaths occur: "   Delivery "   Immediate post-‐partum period

"   Low access to essenBal maternal health services

"   IMR: 48 naBonally; 94.2 in the east "   Under Five Mortality Rate:

"   62 naBonally "   141.9 in the east

"   Highest in Southeast Asia UNICEF report 2013

10

11

Source: Ministry of Health, Myanmar

Global Tuberculosis report WHO-‐2013; Beyrer 2006

•  High burden of CD: tuberculosis (TB), malaria and HIV/AIDS •  Top three naBonal priority diseases of Myanmar (MOH, 2013)

12

13 Num

ber o

f you

ths living with

HIV

14

Source: World Health OrganizaHon -‐ Noncommunicable Diseases (NCD) Country Profiles, 2014.

Five Risk Factors 1.  Dietary risks 2.  Tobacco smoking 3.  Household air polluBon from

solid fuels 4.  High blood pressure 5.  High fasBng plasma blood sugar (IHME, 2010)

Colonial Period: British Health

System"

After independence: Health System was

temporarily interrupted"

Democratization Period"

Military Regime"The first major reform to achieve UHC (Health for

All)"

"   Lack of government investment in healthcare

"   RestricBon of NGO provision of health services

✓ EradicaBon of smallpox 1977

✓ EliminaBon of leprosy, trachoma, poliomyeliBs, and iodine-‐deficiency

disorders

❖  A pluralisBc mix of public and private systems both in financing and provision

17

The WHO Health Systems Framework

Union Minister for Health

Deputy Minister

❖  NaHonal Health Policy ❖ NaHonal Health Plan ❖  Myanmar Health Vision 2030 ❖  Rural Health Development Plan

Deputy Minister

UN Agencies, Bilateral, INGOs, …

Other Ministries NaHonal NGOs, Private Sector

Permanent Secretary Office

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Department of TradiBonal Medicine

Department of Medical Research Department of FDA

Department of Medical Care

Department of Public Health

Department of health professional Resource development and management

●  The government used to be the main source of financing ●  Private out-‐of-‐pocket (OOP) payment became the main source of finance: cost

sharing in 1993 ●  Total health expenditure in Myanmar: 2.0–2.4% of its GDP between 2001 -‐2011 ●  The lowest among countries in the World Health OrganizaBon ●  Donor contribuHons remain substanBal, at 7% of total health expenditure in

2011 (half what the government spends on health).

19

Source: Asia Pacific Observatory on Health Systems and Policies

Source: Department of Health Planning, Ministry of Health, Myanmar

0.0%

25.0%

50.0%

75.0%

100.0%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

GGHE as % of THE PrivHE as % of THE

20

% of total health

expen

diture

21

% of G

DP

●  Nearly 100% of private health expenditure (2001 -‐2011) ●  Over 30% of households encountered catastrophic health expenditure

(MOH & UNICEF unpublished informaBon, 2012)

24 Out-‐of-‐pocket Health Expenditure in SEAR (1995-‐2011)

% of total health

expen

diture

●  No health insurance system at all in Myanmar ●  Social security system : established in 1956 ◦  For insured workers who are employed in the private sector ◦  For enterprises having more than five employees ◦  Benefits : free medical care during illness, payment of 75% of basic salary

during maternity leave, full salary for one year for severe injuries, cash payments for death and injury, and survivors’ pension

●  The scheme covers less than 1% of the populaHon

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●  The Department of Medical Science : doctors, nurses and health care workers ●  Density of physicians: 0.501 per 1000 populaBon ●  It was sBll far below the global standard of 2.28 health workers per 1000 populaBon ●  UnderproducHon of dental surgeons, pharmacists and technicians as compared to doctors

and nurses. ●  Limited registraHon for foreign doctors to work in Myanmar

26

Source: Ministry of Health, Myanmar, unpublished data

28


ScaZer plot showing discrepancy index of hospital beds and hospital uHlizaHon

●  Looking at the distribuBon of health care faciliBes and beds across the country, inequiBes are evident.

●  A discrepancy index lower than 1.0 means that a region or state has fewer beds per 1000 populaBon than the naBonal average (1.0).

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EssenHal Medicine List ●  The Myanmar EssenBal Drugs Programme has revised the NaBonal List of

EssenBal Medicines ●  The Central Medical Store Depot (CMSD) procured a subset of 92 medicines from

the essenBal medicine list in 2010 ●  The Ministry of Finance did not provide enough funds to procure all the needed

essenBal medicine (Holloway, 2011) Ministry of Health, Myanmar, unpublished data

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●  General radiography (e.g. X-‐ray machines) represents as most basic equipment available at township and staBon hospitals across the country.

●  Computed tomography (CT) was only available in Yangon and Mandalay General Hospitals unBl 2012.

●  Five magneBc resonance imaging (MRI) scanners are operated in big ciBes. ●  There is a need to strengthen regular maintenance mechanism of medical

devices.

32 Source: Asia Pacific Observatory on Health Systems and Policies


●  Comprises hospital informaBon, public-‐health informaBon, human-‐resources informaBon and logisBcal informaBon

●  Data are collected manually by individual using standardized forms ●  DisseminaBon of staBsBcs : an annual public health staHsHcs report ●  Due to lack of adequate resources and capacity, populaBon-‐based surveys could

not be carried out as frequently as needed

33

Information Technology

Trends in Internet Users in Government Sector and General Public

35

Patient"

Rural Health Center"

Urban Health Center"

Small clinics run by GPs"

Traditional Medicine"

Station Hospital"

Village Volunteers or Midwifes"

Township Hospital"

District Hospital"

Public Tertiary Hospital"

Private Tertiary Hospital"

Private Hospital"

Rural A

rea

Urban

Area

Traditional Medicine Clinics"

SECONDARY CARE TERTIARY CARE PRIMARY CARE

●  Second worst in terms of ‘overall health system performance’ by the WHO in 2000

●  OOP payment is the highest in the world, at 81% of total health expenditures

●  EsBmated three-‐quarters of Myanmar’s ciBzens find themselves with very limited access to essenBal health services

World Bank (2012)

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Equity of Access to ReproducHve Health Services Among Youths in Poor CommuniHes of Mandalay City

Phyu Phyu Thin Zaw, Tippawan Liabsueltrakul, Edward McNeil, Thein Thein Htay BMC Health Serv Res. 2012 Dec 15;12:458. doi: 10.1186/1472-‐6963-‐12-‐458.

Map of Myanmar

Thailand

India

China Mandalay city "   PopulaBon:

nearly 1 million "   EsBmated 10 ‘resource-‐

limited’ suburban communiBes

"   50,000 living in ‘resource-‐limited’ suburban communiBes

Study Design Community-‐based cross-‐secBonal study Part I :QuanBtaBve methods Part II: QualitaBve methods

Study seing All resource-‐limited suburban

communiBes in Mandalay city

Map of Mandalay city"

"  Formal seZlements "  Riverbank seZlements "  Polakee seZlements

Data collecHon at one of the Polakee CommuniHes

I really want to go to school."

During data collecHon at one of the Polakee CommuniHes

•  Geographical accessibility (79%) •  Financial accessibility (19%) •  Overall, only 34% were able to access at least one RH service centre within

30 minutes walk at an affordable cost and were aware that the service existed.

Factor Adjusted OR (95% CI) P-value*

Youth's place of residence: ref.= Formal Settlements < 0.001

Polakee Settlements 0.36 (0.15-0.84)

Riverbank Settlements 0.29 (0.16-0.52)

LogisBc regression analysis adjusBng all confounding factors OR: Odds RaBo; CI:Confidence Interval

●  Significant increase in health expenditures, which raise the share of GDP allocated to health ◦  From 2.4% in 2012 to 3.14% in 2013 and 3.82% in 2015 ◦  Nine fold increase from 2011 to 2015 ◦  Share of Public Health Expenditure in Total Health Expenditure from 20% to 34%

●  Focus on medicines, medical equipment, and building infrastructure for health insurance ●  Level of health investment is sBll low compared to the demand for health care ●  SBll the lowest compared to other countries in SEAR

45

Department of Health’s State and Region Budget AllocaHon

0.

7500.

15000.

22500.

30000.

Kachin

Kayah

Karen

Chin

Saga

ing

Tanintha

ryi

Bago

Mag

way

Man

dalay

Nay Pyi Taw

Mon

Rakhaing

Yang

on

Shan

(S)

Shan

(N)

Shan

(East)

Ayeyarwad

dy

2012-‐13 2013-‐14

2014-‐15

Source: Department of Health Planning, Ministry of Health, Myanmar

47

"   The Social Security Law (August 2012) "   Full medical reimbursement for every civil

servant (Civil Servant Medical Benefit Scheme) in 2016

"   Expansion of payroll tax financed social health insurance for formal sector (private and civil servant)

"   Development of new social protection policy (2014) to provide health and social benefit for informal sectors

"   Stakeholders’ meetings for development of feasible private health insurance for affordable population Department of Health Planning, MOH"

Three mechanism to cover this informal sector: ● Full contribuBons by members (the Philippines) ● ParBally subsidized by the Government either central or local (Vietnam, China) ● Covered by tax financed scheme (Thailand)

48

●  Human Resources for Health Master Plan: prepared in 2012 for the next 20–30 years ●  AppoinHng new health care workers:

●  Many professionals graduated, but were not employed by the government. ●  Over 28 000 registered medical doctors: about 12 000 were employed by public agencies

●  Increased salary: Doctors (from 150 US$ to 250 US$) ●  Expansion of hospitals and beds provision ●  30 CT scanners by the end of 2013: available in the general hospitals of all region and state

Hospitals. ●  Supplied essenHal drugs to the hospitals (Quick-‐Win approaches)

49

(MOH, 2013)

●  CollaboraBon with various actors in Health Sector since 2011 ●  The Three Millennium Development Goals (3MDG) Fund started in 2013 ●  Many other internaBonal nongovernmental organizaBons INGOs (e.g. PATH,

MSI, Save the Children, World Vision, Oxfam, Medecins Sans FronBeres, AMDA, ADRA, CARE InternaBonal, Burnet InsBtute, Merlyn, Malteser)

●  Working separately to finance specific health-‐development programmes

51

Source: Stephan Lock, Global PracBces, 2013

"   Health-care systems are diverse in SEAR""   Range from dominant tax-based financing to

social insurance and high Out-of-pocket OOP payments"

"   Government spending is generally low in ASEAN, except Thailand and Brunei"

"   Singapore’s health system is the best based on international assessments"

"   Thailand’s Universal Health Coverage: the most successful story reaching the poor (98% coverage)"

"   Increased government health spending: the more significant gains"

●  Myanmar is facing a very important transiHonal period ●  82% of total health spending in Myanmar is out-‐of-‐pocket, the highest in the

world ●  The recent increase in government spending for health is encouraging; however

it is not sufficient ●  Social ProtecHon System is in the developmental stage ●  Financial-‐risk protecHon for the majority of the populaBon who are poor and

from informal sectors is sBll lacking

53

●  Human resources for health are constrained ●  Job saHsfacHon among health care provider is unsaBsfactory ●  InequiHes in distribuHon of the health workforce, parBcularly at the most

peripheral level of the system ●  Very weak health informaHon system ●  A large influx of internaHonal development partners and donor funding

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1.   Equity of access to health care: of vital importance 2.   Government commitment: more investment in health 3.   InternaHonal aid: adhere to the Paris DeclaraBon on Aid EffecBveness 4.  The country’s future healthcare advancements will most likely stem from the

private sector: appropriate policies should be considered 5.  No major evaluaHon or impact study has been carried out so far specifically linked

to these reforms and such studies are strongly suggested

55

1.  Asian Development Bank (ADB) (1996). Country synthesis of post evaluaBon finding in Myanmar. Manila: ADB Post EvaluaBon Office.

2.  Asian Development Bank (ADB) (2012). Myanmar in transiBon: opportuniBes and challenges.22 February 2013 3.  Central StaBsBcal OrganizaBon (CSO) (2009). StaBsBcal year book 2008. Nay Pyi Taw: CSO, Ministry of NaBonal Planning and

Economic Development. 4.  Central StaBsBcal OrganizaBon (CSO) (2012). StaBsBcal year book 2011. Nay Pyi Taw: CSO, Ministry of NaBonal Planning and

Economic Development. 5.  Department of Health NaBonal Tuberculosis Programme (DOH-‐NTP) (2011). The five-‐year NaBonal Strategic Plan (NSP) (2011–

2015). Nay Pyi Taw: DOH. 6.  Health System in TransiBon, The Republic of Union of Myanmar, Health System Review, Asia Health Observatory on Health

Systems and Policies 7.  World Health OrganizaBon (WHO) (2000). The world health report 2000. Health systems: improving performance. Geneva: WHO

(hsp:// www.who.int/whr/2000/en/whr00_en.pdf, accessed 26 November 2013]. 8.  Handler A, Issel M, Turnock B. A Conceptual Framework to Measure Performance of the Public Health System. American Journal

of Public Health. 2001;91(8):1235-‐1239. 9.  Dhillon PK, Jeemon P, Arora NK, et al. Status of epidemiology in the WHO South-‐East Asia region: burden of disease,

determinants of health and epidemiological research, workforce and training capacity. InternaNonal Journal of Epidemiology. 2012;41(3):847-‐860. doi:10.1093/ije/dys046. 56

●  Prof. Karen Eggleston and all the members of APARC ●  WHO-‐HRP for the financial support ●  DMR-‐UM and Ministry of Health (Myanmar) ●  My research team as well as all the poor and marginalized

groups from Myanmar

57

THANK YOU!

Welcome to Myanmar, the Golden Land!"

healthsystemtransformation inmyanmar re the … · 2016" !expansion of payroll tax financed...

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